The PLoS study reveals the obvious: pharmaceutical marketing affects prescribing. Pharma would not spend all the money they do on marketing if it didn’t work. In addition, they have a fiduciary responsibility to their share holders to make providers (and some might argue the public) aware of their products.

The question is not really whether or not pharmaceutical marketing increases prescribing, the question is whether or not this is bad. The PLoS study also points out that increased marketing is associated with increased costs. For some reason, our society only seems to equate “bad” with increased costs of prescription drugs. Those against health reform are fearful that a government controlled health care system will ration care and not allow us to have easy access to MRI’s or robotic prostate surgeries. Better care costs more money. Specialists cost more than generalists. Yet, it seems like many are only concerned about medication costs. This is likely because the public, due to 3rd party payers, are most impacted by their increase prescription co-pays and not from the high costs of MRI’s or stents. Generics are certainly cheaper, but should physicians always prescribe a generic medication? Clearly not.

Thus, even though marketing increases branded prescribing and therefore costs, this is not necessarily bad for patients. This is where I have a problem with the article which states that pharmaceutical promotions lead to “lower quality” prescribing. The evidence is just not there, even in their comprehensive review of the literature. They cite 10 studies of which one did not show a difference, and one I could not find because the reference was incomplete. Of the 8 studies I reviewed, I would only consider 3 to show a possible association of quality. Of the 5 that they claim demonstrate marketing associated with lower quality or irrational prescribing;
-one is a study of 22 residents from 1996 recalling use of cephalosporins for Lyme disease in patients with heart block. Residents who attended pharma sponsored grand rounds were more likely to prescribe the therapy (saving lives) but were also more likely to prescribe unnecessarily (extra cost). In other words, the residents who didn’t attend grand rounds were more likely to kill patients

- another study showed that deaths from Darvon didn’t decrease after government warnings about potential seizures. The implication is that evil drug reps did this. However, it could be that the government just didn’t do that good of a job. No data here on docs that did or did not receive marketing

-similarly another study showed that “Dear Dr.” letters warning about possible seizures from tramadol didn’t decrease sales. I love tramadol. I will use it over a narcotic for chronic pain if I can, because prescription narcotics represent that vast majority of opoid abuse (way more than heroin) in this country.

-another non-US study showed that GP’s that met with drug reps were more likely to write non-formulary prescriptions. More expensive for the UK, yes. Bad for UK patients, unclear.

-one study that “proves” lower quality showed that doctors who recognized drug ads were more likely to prescribe them. Maybe doctors who read journals and can remember what they see actually prescribed the correct medicine.

Of the 3 studies that could be possibly considered evidence that drug company marketing lead to bad prescribing:

-one was a study of GP’s in the Netherlands that focused on cooperation with pharmacists. They used a non-validated score card to show that GP’s who met with reps had a lower quality score which was based on many variables including formulary status and how cooperative they were with pharmacists. Possible evidence, but weak at best

- A 1977 study showed that providers who were more skeptical of drug reps were less like to prescribe a very dangerous drug. Interestingly, visits by drug reps DIDNOT impact prescribing, only skeptical attitude.

Thus, in my analysis of the PLoS study that supposedly shows that drug company marketing adversely affects provider prescribing practices (not including increased cost), there is only one study that really demonstrates this. Here is the link

It is an Australian study done in 1999. Cases were given to GP’s and appropriateness of prescribing certain medications were rated. They found physicians who were more accepting of pharma more likely to prescribe appetite suppressants, calcium channel blockers, angiotensin 2 receptor, bezodiazepines, and SSRI’s for social phobia. Though I think this is a valid study, I do have some reservations. Appetite suppressants and benzos are not marketed by pharma (maybe they were back in the mid to late 90â€²s). Calcium channel blockers were shown in the ASCOT (UK) but not ALLHAT (US) study to be better than diuretics, and NICE guidelines (opposed to the US guidelines) actually recommend ACE inhibitors and CCB’s over thiazide diuretics for many patients, so maybe this “bad” behavior wasn’t that bad. I think prescribing SSRI’s for social phobia, it is likely controversial whether or not this is inappropriate. However, there is clearly no benefit of the newer expensive ARB’s over the generic ACE’s. It should also be noted that this study is not published in a journal, but posted on the healthy skepticism site which is extremely biased against the industry.

In summary, there is not question that pharma marketing increases prescribing and costs. The question is whether or not it harms patients. The authors of the PLoS study go out of their way to prove this point, but really have little to show. In my experience, there are probably some instances where pharma marketing harms patients (the Vioxx case is a perfect example), but there are many examples of where pharma marketing leads to increased appropriate prescribing, leading to patient benefit.

Disclosure: This is a guest post written by a HCP who has requested that his name remain anonymous

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